C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.05
Each home and community-based setting must comply with the requirements of the Global HCBS Waiver Person-Centered Planning and Settings Rule ("Global HCBS Rule"), MaineCare Benefits Manual, Chapter 1, Section 6.
In addition, the following additional settings requirements apply to Community Support Services, and Work Support Group services:
Assistive Technology includes;
In order to receive Career Planning services, the Member's Person-Centered Service Plan must identify the need to explore work, identify a career direction, and describe how the Career Planning services will be used to achieve those goals.
Career Planning services can be provided within a variety of community settings such as a Career Center, the community and local business and must be documented in the Person-Centered Service Plan with related goals.
The cost of Transportation related to the provision of Career Planning is a component of the rate paid for the service.
Communication Aids include:
Only Communication Aids that cannot be obtained as a covered service under other sections of the MaineCare Benefits Manual may be reimbursed under this Section. For Communication Aids costing more than five hundred dollars ($500), the Member must obtain documentation from a licensed speech-language pathologist, Audiologist or Assistive Technology Professional (ATP) assuring the medical necessity of the devices or services.
Community Support is intended to be flexible, responsive and provided to Members as defined by the Member's choice and needs, including non-disability specific community settings, as documented in the Member's PCSP.
Community Support takes place in a non-residential setting, separate from the Member's private residence or other residential living arrangement; however, this service can originate or terminate in the Member's private residence or other residential living arrangement. Community Support may not be provided in a PNMI, Agency Group Home, Shared Living, or any institutional setting.
Community Support can be provided in general community places of the Member's choosing or may be in an agency setting that complies with the Global HCBS Rule.
Community Support allows for opportunities for career exploration and the facilitation of discussions about the benefits of working. Activities and discussions related to work should be relevant to identifying a Member's employment interests, their individual strengths as related to employment, employment goals, and the conditions, such as workplace policies and safety, necessary for the Member to achieve and maintain successful employment. Use of Job Clubs, business tours, soft skill building curriculums, volunteer opportunities and skill building all are allowable under Community Supports to assist the Member on a Path to Employment and must be documented in a Member's plan.
Community Support may also be used to provide supported retirement activities. As some people get older (55 plus) they may no longer desire to work and may need supports to assist them in meaningful retirement activities in their communities. This might involve altering schedules to allow for more rest time throughout the day, support to participate in hobbies, clubs and/ or other senior related activities in their communities.
Community Support is separated into three tiers of service delivery: Community Only-Individual, Community Only-Group, and Center-Based, to support individualized needs of the participant population more broadly. The Community Only tiers (individual and group) are delivered outside of a participant's home or facility setting. The Center-Based tier is delivered from a facility setting but must ensure community integration and community inclusion to the greatest extent possible for participants as documented in the Person-Centered Service Plan. Community inclusion is the intentional process of connecting HCBS waiver participants and their families to other people in the community; identifying and securing generic, paid and natural supports; and supporting relationship development, contribution and reciprocity to support participants to be actively engaged and valued participants of the broader community.
The community support tiers are as follows:
A Member may not receive Community Support while enrolled in high school. Community Support cannot be provided in the Member's place of employment. The cost of transportation related to the provision of Community Support is a component of the rate paid for the service and is not separately billable.
Nothing in this rule prohibits one-to-one (1:1) service delivery.
On Behalf Of is a component of Community Support and is included in the established authorization and is not a separate billable activity.
Consultation is available in the following specialties: Occupational Therapy (OT), Physical Therapy (PT), Speech Therapy, Behavioral and Psychological services. The provider of this service must be a Licensed Occupational Therapist (OT/L) for Occupational Therapy Consultation or a Registered Physical Therapist (RPT) for Physical Therapy Consultation or have a Certificate of Clinical Competence-Speech Pathology (CCC-SP) for Speech Therapy Consultation. For Psychological Consultation, the provider of this service must be a Licensed Psychological Examiner or Licensed Clinical Psychologist. For Behavioral Consultation, the provider of this service must be a Licensed Clinical Social Worker (LCSW), Licensed Clinical Professional Counselor (LCPC) or a Board Certified Behavior Analyst (BCBA). Reimbursement for Consultation Services may only be made to those providers not already reimbursed for consultation as part of another service. Personnel who provide services under Targeted Case Management, Section 13 of the MaineCare Benefits Manual may not be reimbursed for Consultation Services.
Emergency Crisis Intervention services must be authorized by a primary designated DHHS representative without the PCSP documentation this is permitted for a period of two weeks only. Outside of regular business hours, a secondary designated DHHS representative may authorize Crisis Intervention until the next business day only. Ongoing Crisis Intervention services must be recommended by the Planning Team and documented in the PCSP before the DHHS will authorize any further services for
reimbursement. For ongoing Crisis Intervention Services, the Planning Team must document the following:
The nature of the ongoing crisis needs; Any recurring patterns, behaviors, or challenges that the service will address; The inability of currently- authorized habilitative services or direct support staffing to address the need; The expected duration and number of hours needed; How Crisis Intervention Services will be utilized; and A plan to remove the need for ongoing Crisis Intervention.Progress notes must indicate that Crisis Intervention Services were provided, even if the services are provided in conjunction with Home Support and/or Community Support Services.
Crisis Intervention Services may only be provided by staff employed or contracted by an approved provider enrolled in MaineCare.
Employment Specialist Services are provided by an Employment Specialist, who may work either independently or under the auspices of a Supported Employment provider but must have completed the approved Employment Specialist training as outlined by DHHS in order to provide Employment Specialist Services. The need for continued Employment Specialist Services must be documented in a PCSP as necessary to maintain employment over time.
Employment Specialist Services are provided at work locations where non-disabled individuals are employed as well as in entrepreneurial situations. Employment Specialist Services may be utilized to assist a Member to establish and/or sustain a business venture that is income-producing. MaineCare funds may not be used to defray the expenses associated with the start-up or operating a business. The cost of transportation related to the provision of Employment Specialist Services is a component of the rate paid for the service.
On Behalf Of will continue as a component of Employment Specialist Services Support and is included in the established authorization and is not a separate billable activity.
Employment Specialist Services are provided on an intermittent basis with a maximum of ten (10) hours each month. Nothing in this rule prohibits a Member from working under a Special Minimum Wage Certificate issued by the Department of Labor under the Fair Labor Standards Act. Employment Specialist Services cannot be provided at the same time as Work Support-Group or Work Support-Individual.
Adaptations commonly include:
Bathroom modifications; Widening of doorways; Light, motion, voice and electronically activated devices; Fire safety adaptations; Air filtration devices; Ramps and grab-bars; Lifts (can include barrier-free track lifts); Specialized electric and plumbing systems for medical equipment and supplies; Lexan windows (non-breakable for health and safety purposes); Specialized flooring (to improve mobility and sanitation).Items not included above but which have been recommended in a Person-Centered Service Plan are subject to approval by DHHS for reimbursement. DHHS does not cover those adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the Member. Adaptations that add to the total square footage of the home are also excluded from this benefit except when necessary to complete an adaptation (e.g. in order to improve entrance/egress to a residence or to configure a bathroom to accommodate a wheelchair). In-floor radiant heating is not allowable. General household repairs are not included in this benefit.
All services must be provided in accordance with applicable local, State or Federal building codes.
Home AccessibilityAdaptations may not be furnished to adapt living arrangements that are owned or leased by providers of waiver services. If the family is the paid provider, this service is not available.
There must be at least one staff person in the same setting as Members receiving services at all times (24/7) that is able to respond immediately to the requests/needs for assistance from the Members in the setting. The Department reimburses for the delivery of a service to a Member and that assumes that the provider is awake.
Members cannot be made to attend a day program (any other service or support other than Home Support) if they choose to stay home, would prefer to come home after a job or doctor's appointment in the middle of the day, if they are ill, or otherwise choose to remain at home.
Payments are not made for room and board, the cost of facility maintenance, upkeep, or improvement. The cost of transportation is included in the residential habilitation rate.
Payment is not made for the cost of room and board, including the cost of building maintenance, upkeep and improvement. Cost of room and board is paid for separately by a combination of participant funds (e.g. SSI) and other state contracted funds.
Payment is not made directly or indirectly to Members of the participant's immediate family, except as provided 21.06-8 of this rule.
The cost of transportation related to the provision of Home Support is a component of the rate paid for the service.
An increased level of support may be available for Members in Family Centered Support based on the documented needs of the Member as reviewed and approved by the CRT. The Member must require an increased level of staffing as documented in the Member's Person-Centered Service Plan. Refer to Appendix I for more information.
Providers must develop methods, procedures, and activities to facilitate meaningful days and independent living choices about activities/services/staff for the Member.
Procedures must be in place for individual(s) to access needed medical and other services to facilitate health and well-being.
Home Support-Quarter Hour services include a combination of hands-on care, habilitative supports, skill development and assistance with Activities of Daily Living. Supports provided shall be aimed at teaching the person to increase his or her skills and self-reliance.
Examples of support include:
The Home Support-Quarter Hour service includes transportation furnished by the provider during the course of the service.
Payment is not made for the cost of room and board, including the cost of building maintenance, upkeep and improvement.
Payment is not made directly, or indirectly, to Members of the Member's immediate family.
If a Member chooses this service, the Member's Person-Centered Service Plan must include a safety/risk plan that identifies that identifies emergency back-up arrangements.
The use of this service is based upon the Member's assessed needs and the resulting Person-Centered Service Plan. The PCSP reflects the Member's consent and commitment to the plan elements including all assistive communication, environmental control and safety components. An Assistive Technology Assessment must be completed by a qualified provider. Prior to the finalization of the Person-Centered Service Plan the Case Manager and the Member with the assistance of the Planning Team will ensure the appropriateness of the identified assistive technology.
All Remote Support Services must be provided in real time. All electronic systems must have back-up power connections to ensure functionality in case of loss of electric power. Providers must comply with all federal, state and local regulations that apply to its business including but not limited to the "Electronic Communications Privacy Act of 1986 ". Any services that use networked services must comply with HIPAA requirements.
There is no overlap between Assistive Technology and Home Support Remote Support. As set forth in § 21.05-2, Assistive Technology may be used to provide for assessments, equipment, and the cost of the monthly data transmission utility necessary to facilitate Home Support-Remote Support services. Home Support-Remote Support provides the staff that monitor the Member.
There are two types of Remote Support: Interactive Support and Monitor Only. Chapter III reflects the billing for each type. Interactive Support includes only the time that staff is actively engaging a Member in 1 to 1 direct support through the use of the Assistive Technology Device. Monitor Only is when Assistive Technology equipment is being used to monitor the Member without interacting.
Transportation services for Section 21 services are provided under the MaineCare Benefits Manual, Section 113 (Non-Emergency Medical Transportation Services).
A provider may only be reimbursed for providing transportation services when the cost of transportation is not a component of a rate paid for another service.
Whenever possible, family, neighbors, friends, or community agencies, which can provide this service without charge, must be utilized.
Relatives and Legal guardians may only be reimbursed by the broker if they indicate that they are unable to transport at no charge or there is no other viable option and there is a recommendation by the planning team.
The service may be provided to up to three (3) Members at once. When the service is provided to a group, the appropriate group rate must be billed.
The Shared Living provider maintains a supportive home environment that promotes community inclusion with an appropriate level of support and supervision.
The Shared Living Provider is required to maintain a clean and healthy living environment addressing any necessary Member-specific environmental or safety standards (see Appendix V).
Additionally, the Shared Living Provider shall:
The Administrative Oversight Agency supports the provider in fulfilling the requirements and obligations agreed upon by DHHS, the Administrative Oversight Agency, and the Member's Planning Team as documented in the Member's Person-Centered Service Plan.
For this service, Respite is a component of the rate paid to the Administrative Oversight Agency and therefore is not a separately billable service. The record must accurately reflect the Member's location during the receipt of Respite Services.
An increased level of support may be available for Members in Shared Living based on the documented needs of the Member, as reviewed and approved by the CRT. When the Member requires an increased level of staffing it must be documented in the Member's Person-Centered Service Plan. The increased level of support is not to be used as respite or in place of the primary provider. See Appendix I for additional requirements.
For Specialized Medical Equipment and Supplies costing more than five hundred dollars ($500), the Member must submit documentation to the Department from a physician or other appropriate professional such as an occupational, physical, or speech therapist assuring that the purchase is appropriate to meet the Member's need and is medically necessary.
Specialized Medical Equipment and Supplies are limited to only Specialized Medical Equipment and Supplies that cannot be obtained as a covered service under other sections of the MaineCare Benefits Manual. Proof of attempts to obtain requested services under other MaineCare sections may be required for approval.
Examples of this benefit may include but are not limited to the following:
Work Support-Group is provided at the Member's place of employment.
Work Support-Group comprises services and training activities that are provided in regular business, industry and community settings for groups of two to six Members. Mobile work crews and business-based workgroups (enclaves) employing small groups of workers in employment in the community are examples of the models allowed.
Work Support-Group must be provided in a manner that promotes the integration into the workplace and interaction between Members and people without disabilities in those workplaces. The primary focus of the support is job related and also encompasses adherence to workplace policies, safety, productivity, dress code, work schedule, building co-worker and supervisor relationships, hygiene and self-care.
To receive this service, a Member must have received an assessment and services under the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act, and the need for on-going support must have been determined and documented in the Person-Centered Service Plan.
The outcome of this service must be sustained paid employment and work experience leading to further career development and individual integrated community-based employment for which the Member is compensated at or above the minimum wage, and not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.
Work Support-Group does not include vocational services provided in a facility-based work setting in specialized facilities that are not part of the general workforce. Documentation must be maintained in the file of each Member receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act ( 20 U.S.C. § 1401et seq.).
Work Support-Group does not include volunteer work.
Work Support-Group cannot be used to cover incentive payments, subsidies, or unrelated vocational training expenses such as the following:
The cost of transportation related to the provision of Work Support-Group is a component of the rate paid for the service.
No more than six (6) Members at a time may be supervised by a Direct Support Professional. The appropriate group rate must be billed.
Information must be provided to the Member at least yearly that career planning and individual employment is available to the Member in order to make an informed decision regarding the services the Member receives.
The Ticket to Work Program (TTW) and Milestone payments do not conflict with CMS regulatory requirements and do not constitute an overpayment of Federal dollars for services provided since payments are made for outcome, rather than for a Medicaid service rendered.
Work Support-Individual must be provided to the Member in an integrated Employment Setting in the general workforce. The Member must be compensated at or above the minimum wage, and not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.
This service is provided after the Member has received an assessment and services under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act and need for on-going support has been determined and documented in the Person-Centered Service Plan, along with the Member's health and safety needs within the work place.
Work Support-Individual may be provided to self-employed Members where the Member requires support operating his or her own business.
Support may be used for customized employment for Members with severe disabilities to include long term support to successfully maintain a job due to the ongoing nature of the Member's support needs, changes in life situation, or evolving and changing job responsibilities.
Work Support-Individual does not include volunteer work.
Documentation must be in the file of each Member receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act ( 20 U.S.C. 1401et seq.).
Work Support-Individual cannot be used to cover incentive payments, subsidies, or unrelated vocational training expenses such as the following:
The cost of transportation related to the provision of Work Support is a component of the rate paid for the service.
The Ticket to Work Program (TTW) and Milestone payments do not conflict with CMS regulatory requirements and do not constitute an overpayment of Federal dollars for services provided since payments are made for outcome, rather than for a Medicaid service rendered.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.05